Basic Information
| Provider Information | |||||||||
| NPI: | 1851309173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST | ||||||||
| Address2: | STE 530 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 513933 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 146749002 | 05 | TX | MEDICAID | 8N8980 | 01 | TX | BCBS PROVIDER # | OTHER | 146749003 | 05 | TX | MEDICAID | 75-2616977-123 | 01 | TX | TRICARE | OTHER | 752616977096 | 01 | TX | TRICARE | OTHER | TIN PLUS 096 | 01 | TX | TRICARE | OTHER | 8Y9250 | 01 | TX | BCBS | OTHER |